Future therapy patients may spend a lot more time exploring virtual environments than sitting on sofas.

In a clinical trial of a new virtual reality treatment for fear of heights, participants reported being much less afraid after using the program for just two weeks. Unlike other VR therapies, which required that a real-life therapist guide patients through treatment, the new system uses an animated avatar to coach patients through ascending a virtual high-rise. This kind of fully automated counseling system, described online July 11 in the Lancet Psychiatry, may make psychological treatments for phobias and other disorders far more accessible.

This is “a huge step forward” for therapeutic VR, says Jennifer Hames, a clinical psychologist at the University of Notre Dame in Indiana, who wasn’t involved in the work. By bringing expert therapy out of the counselor’s office and into primary care clinics — or even people’s homes — the new system could help those who aren’t comfortable or don’t have the means to speak with a therapist face-to-face, she says.

Conquering fear

Study participants completed what the researchers called the Heights Interpretation Questionnaire, which rates fear of heights from 16 to 80 (where 80 is most severe), before treatment, immediately afterward, and two weeks later. People who completed the VR program were much less afraid of heights than they were initially, whereas people who got no treatment were about as afraid as before.

Users immerse themselves in this virtual reality program using a VR headset, handheld controllers and headphones. An animated counselor guides the user through a virtual 10-story office complex, where upper floors overlook a ground-level atrium. On every floor, the user performs tasks designed to test their fear responses and help them learn that they’re safer than they might think. The tasks start out relatively easy — like standing close to a drop-off where a safety barrier gradually lowers — and progress to more difficult challenges — like riding a moving platform out into the open space over the atrium.

By working through these activities, “the person builds up memories that being around heights is safe, and this counteracts the old fear beliefs,” says Daniel Freeman, a clinical psychologist at the University of Oxford.

To test their program’s effectiveness, Freeman and colleagues recruited 100 adult volunteers who were moderately to severely afraid of heights. The researchers randomly assigned 49 people to undergo VR treatment, which involved using the program for about six 30-minute sessions over two weeks, while the other 51 participants received no treatment.

Participants filled out a questionnaire that rated their fear of heights from 16 to 80 (with 80 being most severe), before treatment, immediately afterward, and two weeks later. People who underwent VR treatment dropped about 25 points on average on the questionnaire’s scale, while patients who received no treatment remained stable. Participants who used the VR program found they “could go to places that they wouldn’t have imagined possible,” Freeman says, like steep mountains, rope bridges or simply escalators in shopping malls.

“When I’ve always got anxious about an edge, I could feel the adrenaline in my legs, that fight/flight thing; that’s not happening as much now,” one participant said. “I’m still getting a bit of a reaction to it, both in VR and outside as well, but it’s much more brief, and I can then feel my thighs soften up as I’m not bracing up against that edge.”

While the clinical trial results provide strong evidence that the new VR program mitigates fear better than no treatment at all, researchers still need to investigate how VR therapy stacks up against sessions with a therapist, Hames says. And since Freeman’s team only tracked treatment effects up to a couple of weeks after their experiment, it remains to be seen how long the effects of this therapy last — although previous research on therapist-led VR treatment have shown lasting impacts for at least a year.

While fully automated VR therapy may be good news for people who fear heights, it’s not clear how well this type of system could address more complex mental health issues, says Mark Hayward, a clinical psychologist at the University of Sussex in England whose commentary on the study appears in the same issue of the Lancet Psychiatry. Virtual environments may be well suited for helping people who fear everyday situations, like those who suffer from common phobias, social anxiety or paranoia, Hayward says. But when it comes to helping people with more severe symptoms, like psychosis, VR probably won’t stand in for trained therapists any time soon.

“We can’t get carried away and say we can automate all [mental health] treatment,” says Albert Rizzo, a clinical virtual reality developer at the University of Southern California in Playa Vista not involved in the work. But the new standalone system for curbing fear of heights is “an excellent first effort.”